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There is no recommendation in Europe for the use of ketamine in patients with chronic pain. The heterogeneity of practice highlights the need to seek the advice of experts in order to establish a national consensus. This Delphi survey aimed to reach a national consensus on the use of ketamine in chronic pain in Pain clinics.A collaborative four-round internet-based questionnaire was used. It was created after literature search on ketamine administration in chronic pain and included about 96 items. It discussed utility and advantages, adverse events and deleterious aspects, methods of administration, concomitant treatments and assessment of results.Twenty-eight experts completed all rounds of the survey with a total of 81.3% items reaching a consensual answer. Neuropathic pain represents the first indication to use ketamine, followed, with a good to moderate utility, by other situations (fibromyalgia, complex regional pain syndrome, central neuropathic pain, peripheral neuropathic pain, nociceptive pain, sensitization, opioid withdrawal, palliative care, depression). Experts agreed on the rare occurrence of adverse events. Concerning routes of administration, intravenous infusion with doses of 0.5-0.9 mg/kg/d for 4 days of treatment is preferred. Place of care is hospital, as in- or out-patient, with a quarterly administration of ketamine. Finally, ketamine effectiveness is assessed 1 month after infusion, and experts encourage combination with non-pharmacological treatment.This Delphi survey established a consensus of pain specialists on the use of ketamine in refractory chronic pain, thus providing a basis for future comparative trials.This Delphi survey in chronic pain reached agreement on four main aspects: (1) Priority to treat neuropathic pain with evaluation of effectiveness at 1 month; (2) No deleterious effects in the majority of listed diseases/situations with the absence or3% of suggested adverse events; (3) 0.5-0.9 mg/kg/d IV infusion; (4) Combination with non-pharmacological treatment.

Current therapeutic modalities for fibromyalgia (FM) do not provide satisfactory results and new approaches have to be explored.To assess efficacy and safety of adding a phytotherapy treatment (Fib-19-01) to the current therapeutic regimen in patients with FM.Double-blind controlled trial: women with active FM (Fibromyalgia Index Questionnaire FIQ40) were randomised to receive Fib-19-01 or a food supplement (FS) undistinguishable from Fib-19-01 or no supplementary treatment (NoST). All continued the conventional therapy throughout the 6 month follow-up. Primary endpoint: change in FIQ between Day 0 and month 6 (M6). Secondary Criteria: variation over time FIQ ( repeated measurements), change in Pichot fatigue scale, Pittsburgh Sleep Quality Index (PSQI), SF-12 and Hospital Anxiety and Depression (HAD) scales.100 patients (Intent-To-Treat population) were analyzed. FIQ decreased significantly only in the Fib-19-01 group (P.001) at both week 12 and 24. Improvement was higher for Fib-19-01 (-13.4 ± 18.9) than in the 2 other groups (-5.5 ± 15.6 and -5.6 ± 11.3) despite there was no statistical between-group difference at week 24 in FIQ score (P = .08 and P = .09 respectively). Analysis of variance in repeated measurements of FIQ showed a significant difference between Fib-19-01 and FS throughout the follow-up period (P = .03). Fib-19-01 was superior to both FS and NoST for Pichot scale decrease over time: -4.6 (range -6.9; -2.28), -0.29 (-2.7; 2.1) and -0.72 (-3.1; 1.66) (P = .013 and 0.023 respectively), mental and social SF12 [+8.1 (range 3.5; 12.6), -0.27(range -5.3; 4.8 ) and -0.02 (range -5.0; 4.9 ) P = .02 and 0.018)],HAD depression [-2.0 (range -3.3; -0.7), +0.5 (range -0.9; 1.9 ) and +0.71 (range -0.7; 2.1) P = .013 and 0.007]. No significant difference was found between FS and NoST groups for any outcome. All treatments were well and similarly tolerated.In patients with FM taking conventional therapy, Fib-19-01 has a therapeutic effect on fatigue, emotion and social life, and depression associated with the disease.

Resume Les soins palliatifs (SP) s’adressent aux patients atteints de maladie grave, evolutive ou terminale et les EMSP ont a jouer un role de prevention des situations complexes. Pourtant, apres deux ans d’activite, l’EMSP a constate que 60 % de ses patients etaient en phase terminale lors de la premiere consultation. La premiere hypothese etait que les missions cliniques de l’EMSP etaient peut-etre mal connues par les medecins du CHLS, structure qui comprend a la fois une EMSP et une USP. Afin de verifier cette hypothese, nous avons adresse un questionnaire anonyme a l’ensemble des medecins du CHLS qui collaborent avec l’EMSP, afin d’evaluer leurs connaissances et leurs representations des soins palliatifs. Le taux de reponse de 36 % nous a permis de constater que si la definition des SP est largement connue, les differents moments de la phase palliative (initiale, terminale) et les differences entre l’EMSP et l’USP sont mal connus. De plus, 84 % des medecins savent que les SP ne s’adressent pas uniquement a la phase terminale, mais la majorite estime leur action peu ou moyennement utile avant cette phase. Pourquoi ? L’EMSP souffre probablement d’une representation encore pejorative, mais au-dela, le fonctionnement transversal a peut-etre aussi sa part de responsabilite, engendrant une certaine forme de resistance a la collaboration. Les perspectives pour demain passent donc sans aucun doute par une meilleure (re)connaissance de notre activite clinique, mais aussi par un travail autour des representations des SP afin de maintenir une collaboration rassurante, propice au compagnonnage cher aux SP.